Cycle 1
Health 2024-02-15 · Fire 2024-02-15
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bronx, NY
St Patricks Home
4-star overall rating with 3-star inspections with $51,500 in total fines with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
66 Van Cortlandt Park South, Bronx, NY
(718) 519-2800
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
264
Certified beds
Average residents
259
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Carmelite Sisters For The Aged & Infirm
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,427
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.01
Baseline 18.51% · Performance 19.57% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Healthcare-associated infections
0
Baseline 6.67% · Performance 8.77% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.33
Baseline 32.17% · Performance 37.80% · Measure score 6.33 · Achievement 6.33 · Improvement 0
Adjusted total nurse staffing
1.57
Baseline 3.24 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0.62
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 8.33% · Lower 95% interval 6.58% |
| Discharge to community | 37.88% |
50.57%
12.7 pts worse
|
Worse than the National Rate · Eligible stays 110 · Observed rate 29.09% · Lower 95% interval 29.8% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 90.74% |
95.27%
4.5 pts worse
|
Numerator 147 · Denominator 162 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 162 |
| Discharge self-care score | 60.63% |
53.69%
6.9 pts better
|
Numerator 77 · Denominator 127 |
| Discharge mobility score | 62.99% |
50.94%
12.1 pts better
|
Numerator 80 · Denominator 127 |
| Pressure ulcers or injuries, new or worsened | 1.85% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 162 · Adjusted rate 1.78% |
| Healthcare-associated infections requiring hospitalization | 8.78% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 14.93% · Lower 95% interval 5.46% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 273 |
| Staff flu vaccination coverage | 47.27% |
42%
5.3 pts better
|
Numerator 156 · Denominator 330 |
| Discharge function score | 67.72% |
56.45%
11.3 pts better
|
Numerator 86 · Denominator 127 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 94.74% |
96.28%
1.5 pts worse
|
Numerator 54 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 43.37% |
25.2%
18.2 pts better
|
Numerator 36 · Denominator 83 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.7
0.7 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.3
0.8 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.2%
8.6 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 99.6% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.3%
4.7 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.0%
1.7 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.2% · Q3 1.2% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 82.5% |
18.5%
64 pts worse
|
11.4%
71.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.5% · Q2 81.0% · Q3 86.6% · Q4 92.2% · 4Q avg 82.5% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.1%
1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 7.4% · Q3 4.8% · Q4 4.3% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.1% |
13.5%
9.4 pts better
|
19.6%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.9% · Q3 3.5% · Q4 4.6% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
14.8%
8 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 8.1% · Q3 6.2% · Q4 5.2% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.1% |
15.1%
3 pts better
|
16.3%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 15.8% · Q3 14.4% · Q4 10.5% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.4% |
15.5%
2.1 pts better
|
14.9%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 15.6% · Q3 13.8% · Q4 16.0% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.6%
0.5 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
20.8%
4.5 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 19.8% · Q3 16.7% · Q4 14.4% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.9%
1.6 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 4.2% · Q3 6.7% · Q4 4.1% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
76.7%
13.4 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.5% · Q2 88.6% · Q3 95.8% · Q4 92.4% · 4Q avg 90.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.7%
2.1 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 6.3% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.2%
0.8 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.6% |
78.8%
12.8 pts better
|
79.7%
11.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
20.6%
1.4 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 17.9% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-17 · Fire 2021-11-17
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-09-23 · Fire 2019-09-23
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-02-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-15
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-15
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-16
E · Potential for more than minimal harm
2024-02-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-19
D · Potential for more than minimal harm
2024-02-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-15
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-15
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-03-04
D · Potential for more than minimal harm
2021-11-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-15
E · Potential for more than minimal harm
2019-09-23
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2019-11-25
C · Minimal harm
2019-09-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-25
Inspection history
Recent health citations
G · Actual harm
2024-05-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-05-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-05-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-02
E · Potential for more than minimal harm
2024-02-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-27
D · Potential for more than minimal harm
2021-11-17
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-11-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-11-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-01-16
D · Potential for more than minimal harm
2021-11-17
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2022-01-16
E · Potential for more than minimal harm
2019-09-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-09-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-09-23
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-09-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-09-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-09-23
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-09-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-11-26
Penalties and ownership
What sits behind the stars
$51,500
2024-05-09
Fine
Fine · fine $51,500
Fine
Ownership
Bowden, Mary
Corporate Officer · Individual
Devlin, Mary
Corporate Officer · Individual
Dunleavy, Elizabeth
Corporate Director · Individual
Gallotta, Steven
Corporate Officer · Individual
Heery, Mary
Corporate Officer · Individual
Kasper, Rose Marie
Corporate Officer · Individual
Kenney, Edward
Corporate Officer · Individual
Klump, Kristen
W-2 Managing Employee · Individual
Lehmann, Raphael
Corporate Director · Individual
Lehmann, Raphael
W-2 Managing Employee · Individual
Lynch, Patricia
Corporate Director · Individual
Lynch, Patricia
Corporate Officer · Individual
Lynch, Patricia
W-2 Managing Employee · Individual
Mack, Diane
Corporate Officer · Individual
Moriarty, Michael
Corporate Officer · Individual
Naderhoff, Judith
W-2 Managing Employee · Individual
Randall, Diane
Corporate Officer · Individual
Rawdon, Patricia
Corporate Officer · Individual
Ruiz, Juan
Corporate Director · Individual
Ruiz, Juan
W-2 Managing Employee · Individual
Walsh, Maureen
Corporate Officer · Individual
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
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Bronx, NY
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Methodist Home For Nursing And Rehabilitation
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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